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Author
Topic: Re-infection! (Read 16716 times)

You asked: "What are these people doing as treatment if they have something like that?"

They wait for new medications to come out. A scary scenario, to say the least.

Hellraiser,

You asked:" It's difficult to pin down who is reinfected and I'm a little confused on how it is that they test for reinfection considering the test for HIV isn't for the virus itself but for the antibodies to it."

See Dr. Gallant's answer above. They use different tests to determine the strain variety, if there is reason to believe that someone has been re-infected.

the most convincing case was presented by Bruce Walker at the Barcelona last month. He reported on a patient who was diagnosed and treated within weeks of infection.

is there any other data besides this case?

I found more information about this case here: http://www.nypress.com/article-6207-the-bareback-lie.htmlAccording to Garrett, Walker told the scientists in Barcelona that he’d treated a gay Boston man with anti-HIV drugs immediately after infection for several weeks, as he’d done with more than a dozen other patients. The man seemed to do very well, beating back HIV. But after a month, he was surging with virus, which turned out to be a different strain of HIV–a strain that was, genetically, 12 percent different from the strain with which he’d originally been infected. His "immune system was helpless in the face of the apparently new HIV," Garrett reported. The man told Walker that he’d engaged in unprotected sex with another man within 30 days of his original infection.

What this, tragically, means for a vaccine is that even a strain of HIV close to one that you might be vaccinated against can still cripple your immune system, rendering the vaccination useless. (And there are at least seven classes of HIV, each including many strains.) Cornell University AIDS vaccine researcher John Moore told Garrett: "This case, albeit anecdotal, has shattering implications for the development of a prophylactic vaccine." And what it means for HIV-positive gay men who have unprotected sex with one another is that they can be infected with other, perhaps more powerful strains of HIV, and, chillingly, may be passing on drug-resistant strains, helping to promulgate a super-HIV.

"While it’s true Walker’s patient is ‘only one case,’" Garrett tells me, "it would be disingenuous to suggest there is no other evidence of superinfection, or immune system failure, to recognize secondary HIV infection. In fact, [at the conference] three other superinfection cases were described, and by my count at least 10 others have been cited in recent years. What made Walker’s case stand out is the extraordinary caliber of his work on the case. Nobody has previously tracked so many aspects of the virology and immunology of a case, almost from the moment of infection."

to be honest, that isn't really overwhelming evidence. One man, continuing to engage in unprotected sex, who was probably "re-infected" within the first month of treatment and before reaching UD? I would be more impressed by data showing that someone who had been UD for several years was re-infected, not someone who had barely even started treatment.

Plus they speak of "10 other cases". That's hardly a blip in the total HIV+ community (a point zero, zero, zero something chance) - and of course there's no information given concerning the viral load, etc in those 10 cases. If all of those were people within the first month or so of treatment, who had not yet reached and sustained UD, then it might show reinfection as an issue - but an issue for the untreated and those who have not yet had viral suppression.

I would have been more willing to believe this if that article had instead said:And what it means for HIV-positive gay men, untreated or recently started on HAART, who have unprotected sex with one another is that they can be infected with other, perhaps more powerful strains of HIV, since their strain of infection has not suppressed, and, chillingly, may be passing on drug-resistant strains, helping to promulgate a super-HIV amongst untreated gay men or those only recently starting HAART.

As others have pointed out, it seems reaching UD and staying adherent would act as Prep and stave off any re-infection possibility. Otherwises wouldn't we be seeing reports (even from people in these forums who bareback with other pozzies) becoming reinfected 10 yrs + after their diagnosis?

If you read Dr. Gallant's response closely, he states that the patient was diagnosed and treated within the first weeks of his infection--- true. However, he got diagnosed with a different strain one month later after starting ART for his first infection to which he was responding. Now, your link states that there were three other superinfections explained at that same conference and that they had first hand knowledge of at least 10. Those are the one's they know about. Your link also states that the amt of work necessary to determine re-infection( from almost the moment of infection) is what stood out in this case. As the disease progresses, a rise in viral load is usually looked at as poor adherence. Other factors wouldn't be warranted other than a new geno and pheno. The fact remains it did and can happen. So the question remains: "Do you feel lucky?" (Clint's cool). Wheather it's one, ten or 100 your still rolling the dice. Is it worth the potential to ruin one's HAART combination for the sake of a condom?There are plenty of fun things to do in the bedroom that are safe. Why take the chance?

unfortunately the information you provided (and thank you for it! ) still doesn't seem to provide me the information that I was looking for. I'm not doubting that reinfection is possible, what I'm questioning is exactly WHO is at risk for this phenomon.

For example in the Ottawa case both patients were being treated through a hospital. I am inferring from that, that they were not being successfully treated (as in UD) for 5-10 yrs else why would both patients be in the hospital? Obviously they were either newly diagnosed (perhaps with OIs) or in bad enough health to be hospitalized. It sounds like there were other health factors to consider in why that "reinfection" occurred.

(I would also like to say with this and the previous case I discussed - Damn! Can't these people keep it in their pants long enough to get treated first?!? In the previous case, the guy was already barebacking in the first couple weeks of meds and these guys were in a hospital being treated for their unknown ailments and were busy barebacking. Shoot! I was too sick when I was in the hospital with PCP to think about any kind of sex. Obviously these guys getting diagnosed with HIV didn't teach them a thing about safer sex if they couldn't even wait a couple weeks to not get laid.)

Your other link clearly talks about people being treated for less than 3 years, or people that were non-adherent. That article even goes so far as to state my postulation: "We do know that adherence to treatments may impact and provide protection against the possibility of re-infection occurring (e.g. it may be less likely to occur if both HIV positive partners are currently on treatments with a low or undetectable viral load)."

So as I mentioned previously, all of these cases of "reinfection" seem to be occurring to the newly diagnosed and untreated, the people recently started on treatment who have not yet obtained UD for an extended amt of time, or people with adherence issues (which could have resistance issues or no longer be UD). None of these cases seem to be of people who have remained adherent and been UD for a period of time.

because so far the data doesn't point to this being an issue that I will have to face. it seems, so far, that the only ones at risk of a chance of reinfection are mostly "newbies", who haven't started treatment or in whom the virus has not yet been controlled.

Plus there's still that nagging problem - if Prep works then why wouldn't my being on meds for a decade be the best Prep ever?

Your question:" I'm not doubting that reinfection is possible, what I'm questioning is exactly WHO is at risk for this phenomon."

If you believe (and I know you do) that HAART medications will at sometimes not work depending on the type and amt of mutations you have, then you must also conclude that you could obtain a virus with mutations that would render your medications useless. That being said, theoretically, anyone who barebacks runs the risk . Also, I know you realise that seman still carries a viral load even if the blood is ud.Prep doesn't work everytime. Here's a good Q&A on Prep from the cdc:

you could obtain a virus with mutations that would render your medications useless.

Ah! Now there's a reason I can understand.

Would you have any conjectures then as to why we're not seeing this reinfection phenomon happening throughout the population of HIV+ people who have been in successful treatment for say 5 to 10 years or more?

My conjectures: not enough of them are having sex; not enough of them are sero-sorting; not enough of them are having unprotected sex; not enough are actually being exposed to mutated strains; and not enough have enough viral load in their semen.

I'm wondering what a statistician would say was the likelihood of it's happening. You would need someone on, say, atripla, to have unprotected sex with someone who was completely resistant to atripla, and the first person would have to get re-infected. What is the likelihood?

Veritas, clearly I was wrong above when I said that there were no cases of people on HAART getting re-infected. That also negates what Borzel and I agreed--that not worrying about re-infection would be one reason to start HAART for someone with borderline numbers. Obviously, at the time when I read through those articles (and obviously I did not read every last one) I was highly nervous about my own case and I was looking for information that most closely matched my own case--about re-infection in people not yet on HAART.

We still, of course, do not know whether I myself have been re-infected, and we may never know. We are still waiting for the results of the HIV genotype test to come back, and even when they do they may demonstrate nothing. But I'm really glad I started this thread. I've had HIV for almost six years now (shudder), and in all that time, I can honestly say that I've never given two minutes' thought to the question of reinfection. That's not right. We need to be informed about things before they hit us, not afterwards! Thanks to everyone who's contributed questions and answers on this important topic!

Obviously these guys getting diagnosed with HIV didn't teach them a thing about safer sex if they couldn't even wait a couple weeks to not get laid.

Obviously you being diagnosed with HIV and reading these reports about superinfection, whether they were in people who were UD or not, didn't teach you a thing about safer sex or you wouldn't be so damn gung-ho to keep barebacking left and right. How would you feel if you gave someone else a superinfection?

I'm wondering what a statistician would say was the likelihood of it's happening. You would need someone on, say, atripla, to have unprotected sex with someone who was completely resistant to atripla, and the first person would have to get re-infected. What is the likelihood?

Veritas, clearly I was wrong above when I said that there were no cases of people on HAART getting re-infected. That also negates what Borzel and I agreed--that not worrying about re-infection would be one reason to start HAART for someone with borderline numbers. Obviously, at the time when I read through those articles (and obviously I did not read every last one) I was highly nervous about my own case and I was looking for information that most closely matched my own case--about re-infection in people not yet on HAART.

My understanding of the probabilities involved lets me posit that someone who is on HAART and UD has the same risk of getting a super-infection as he does of being struck by lightning.

Individual probabilities that I take under consideration:--Number of living individuals with resistance to all three drugs in Atripla (example drug) who are out there having sex (and not in a hospital)--Probability of virus transmission for the given sex act you perform--Probability that the virus can infect someone while they are on HAART even if the viral strain has resistance to it (i think it's much less than 1)

I think the three probabilities add up to an infinitesimal number. And by the way - 40 people die each year in the US after being struck by lightning.

Another way to put it - being on HAART reduces your chances of a superinfection by a very large number (i think over 90%). So even while the risk is there - it's much, much smaller. And, of course, you are not a danger to any other individuals who you have sex with. You ended up getting the rough end of this stick - but what if the guy were negative and you passed it on to him (this is just a hypothetical).

Obviously you being diagnosed with HIV and reading these reports about superinfection, whether they were in people who were UD or not, didn't teach you a thing about safer sex or you wouldn't be so damn gung-ho to keep barebacking left and right. How would you feel if you gave someone else a superinfection?

Your message is missing a key logical link. Someone who is UD can not pass a superinfection by definition. Being UD means their cocktail keeps the virus in check since it's not resistant to the mix.

who says I bareback? not I you obviously inferred the wrong thing from my posts. Doh!

However, the barely dozen reports about people with "superinfection" that we've been discussing in this thread doesn't really inspire me yet to believe it's happening to long-term UD pozzies either. Although V did make a good point in the arguement about that , Nestor's aidsmap link ("Unprotected sex between long-term partners with HIV: no evidence for superinfection") says quite the opposite.

(perhaps you should read that article first Ody and then consider my questions/comments about this topic that I've posted in this thread before jumping to your crazy conclusions.)

Well we have two things here. First I presume you missed my point about superinfection. Namely - that someone who is UD on HAART can not pass a superinfection because they don't have one. Being UD means the virus is controlled. If it were resistant - the person would not be UD.

Secondly, I also think it's worth keeping in mind what the probability of transmission of someone who is UD (blood) is - very, very low. Ie the virus has been found in semen while being UD in blood - but how often? It's very unlikely.

First I presume you missed my point about superinfection. Namely - that someone who is UD on HAART can not pass a superinfection because they don't have one. Being UD means the virus is controlled. If it were resistant - the person would not be UD.

Look: The person who causes a superinfection in a second person does not himself have a superinfection, but he causes the second person to have the superinfection.

Person A has virus variant A. He is UD on HAART. His HAART controls his variant-A virus in peripheral blood, but his semen still contains the virus. He is not superinfected.

Person B has virus variant B. He has unprotected sex with Person A, who infects him with variant A. Person B is now infected with two virus variations. He is now superinfected.

Logged

"No one will ever be free so long as there are pestilences."--Albert Camus, "The Plague"

"Mankind can never be free until the last brick in the last church falls on the head of the last priest."--Voltaire

We are all still learning about this disease and to catch everything when your researching a particular issue is next to impossible. I'm hoping your labs were some type of error and if they weren't, you should still be able to take a good combination to get that vl down. Please keep us posted as to what they find. I don't think they will test for a re-infection. However, your geno and pheno should give you the necessary information to come up with a winning strategy.

along with those conjectures you enumerated, I just don't think they are testing for different strains when someone has a ridse in their vl. The cost would be prohibitive and the final treatment decision is based on geno and pheno tests. Heck, there's a lot more info I'd like to know but it's just not available.

do you know if there's any information then about how often "therapy failure", ie a rise in Viral load, is happening? If a rising VL is a sign of reinfection, that's another thing you would think we'd be hearing about in longterm virilocially suppressed individuals, who would then be switching meds (without a test done for the strain).

Most med changes I read about seem to be for convenience or costs sake and/or side effects issues. I don't think I ever much hear of someone sustaining UD for 10 yrs suddenly having unexplained therapy failure and changing meds - unless their bad adherence causes resistance and then, after a genotyping, a med switch usually resolves the issue bringing the client back to UD.

The reason I keep questioning and postulating, is that the issue of "reinfection" in longterm virilocially suppressed individuals seems to be as rare as getting HIV from oral sex. It's sounds like it's one of those minute <1% issues.

Look: The person who causes a superinfection in a second person does not himself have a superinfection, but he causes the second person to have the superinfection.

Person A has virus variant A. He is UD on HAART. His HAART controls his variant-A virus in peripheral blood, but his semen still contains the virus. He is not superinfected.

Person B has virus variant B. He has unprotected sex with Person A, who infects him with variant A. Person B is now infected with two virus variations. He is now superinfected.

Ok - I see. I see how it can happen. For that to happen, Person B's cocktail has to have no impact on Person A's virus, who is keeping it UD in blood but has some VL in semen. It seems possible but extremely unlikely. Ie lottery type odds (assuming you don't actually find such people and set them up with very purpose of testing the hypothesis).

"The researchers conclude that HIV-infected patients who continue risk behaviour are at risk of superinfection “both in the early and established phases of the disease”. They recommend that all patients not on treatment who experience unexpected viral load increases should be screened for superinfection (though the kind of intensive phylogenetic screening used in this study is purely a research tool, costing £10,000 per patient)."

The article suggests that re-infection is common (two out of eight people followed were re-infected) but it also reveals that someone can lose med resistances by getting reinfected:

In the second case the patient acquired a second strain three years after the first. In this case his original virus had two drug resistance mutations. When his viral load increased he was given another resistance test 3.5 years after diagnosis which showed no evidence of the mutations. Analysing previous samples showed he had acquired a superinfection six months previously.

So, what do you think, if your virus is drug resistant, would going out and deliberately getting reinfected by someone without resistances be a good idea? Of course you'd have to make sure it was someone with no other stds.

By the way, the fact this this person was reinfected three years after initial infection would appear to contradict the prevalent idea that reinfection only happens to the newly infected.

More importantly for me, the article does not suggest that faster progression to AIDS is a result of superinfection:

In one case the patient‘s second strain of HIV was drug-resistant. He also experienced a recurrence of acute HIV symptoms which required hospitalisation for suspected meningitis and a large, though temporary decrease in CD4 count. In the other case the patient’s original strain of HIV, which was drug-resistant, was replaced by an apparently stronger non-resistant strain and his viral load increased from around 3000 to half a million. However he maintained a CD4 count over 1000 and his viral load had returned to 3000 a year later.

So, leaving aside resistance issues, in one case the decline in cd4 cells was temporary, and in the other the surge in viral load was temporary. I'm keeping my fingers crossed!

[dodge flames]I personally would not worry too much about superinfection. [/dodge flames]

I'm a big fan of logic and science. There are two arguments that support what Ann said about Occam's razor.

In essence, Occam's Razor means that the simplest explanation is the most likely.

1. The damning evidence: There are a handful of cases of documented superinfection. Yet the vast majority of poz gay men that I know of engage in unprotected sex. This doesn't mean everyone reading this is in that category, but just my basic observations suggest that unprotected sex is pretty common. It's been going on for a while now... so if reinfection and co-infection were significant risks we should be seeing in it many gay men. The daming evidence is that there isn't any. We just don't see lots of people who are coinfected.

2. The conspiracy theory (my personal favorite): Sadly, some people get off on controlling other people's sex lives. This masquerades under the hallucination of morals. Most of this is leveraged on the "my excuse is more powerful then your desire" logic. When you were negative this took the form of "if you disobey me you will wind up poz." Well, that logic doesn't exactly hold water for most of us in here. So the next logic that you can substitute is a slight variation on the same ole scare tactic. "you'll get it again if you don't do what I say." aka reinfection. The Federal government attaches real dollars to safe sex campaigns which encourages ASO's to push safe sex to PWA's. (People with HIV/AIDS).

3. The viral factor: Okay, one of the arguments for reinfection is that you don't want multiple strains. Um, okay, but like many other facets of HIV education it imparts too much intelligence to a virus. The virus mutates constantly and a given individual may have a multitude of mutations at any given time. True, drug resistance can be passed on during the initial infection... but see my first point.... if viral resistance could be passed from person to person, many of us would be in deep trouble.

4. One of the more curious things about HIV is that if someone stops therapy the wild-type strain re-emerges most of the time. This isn't well understood. However, it supports the concept that you might have a resident virus and that displacing the resident virus would be reasonably difficult. After all, what makes HIV difficult to treat is that it assimilates itself into your DNA. The odds of another strain coming along and ripping out your current strain and replacing it are right there with fresh ice in hell. It makes for good news copy and great sci-fi but in my unqualified opinion it doesn't fly.

5. Let's look at the "examples" that have been trotted out by the CDC, whom I consider to be an authoritative source. The best they can offer is this:When Both Partners are Infected: What is the Significance of Superinfection in HIV Transmission?Superinfection is defined as infection by a second strain of HIV after initialinfection by a primary strain has been established [44]. The frequency and timing of superinfection may vary depending upon the population under study and the method of detection. Follow-up of 78 newly infected individuals (none of whom initiated ART while under study) in one clinic revealed that 4 (5%) had acquired a superinfecting strain within 6 to 12 months of initial infection [45]. In a cohort of 36 high-risk Kenyan women screened for HIV-1 superinfection over a 5-year period beginning at primary infection, seven cases of superinfection were detected [46]. In this study superinfection occurred throughout the course of the first infection: during acute infection in two cases, between 1-2 years after infection in three cases, and as late as 5 years after infection in two cases. The clinical consequences of superinfection for an individual vary, but may include accelerated disease progression and the acquisition of drug resistance [47]. The public health consequences of HIV superinfections are unclear. While superinfection can result in recombination between genetically different viruses, and a number of circulating recombinant forms (CRFs) are prevalent in certain geographic areas [48], it has not been demonstrated that such recombination results in the establishment of more transmissible or virulent viruses. There is also evidence that superinfection occurs only rarely in HIV-infected individuals on effective ART [49, 50].

That's pretty vague for an agency that normally uses pretty damning language. They say that in one instance they found a 5% reinfection rate, but then state at the end that it's pretty rare for individuals on ART. The bottom line is they are being pretty vague about it.

In both instances the title of the paper is "failure to find superinfection" not anything more sensational.

Lastly, let's revisit the super-infection cases we do know about. What do they exhibit? Massive risk exposure.

Realisitically the average HIV'r is doing pretty good on the get-laid-scale if they are getting laid once a week on average. That represents 52 exposures per year. I think that most people are at this or below. Someone who is promiscuous may have 300 partners per year, which is a 600% increase in exposures.

The guy who was superinfected in NYC a few years ago (the one that started the superinfection craze) was going to the bathhouse 7 days a week for 7 years and having sex with 20 or so strangers a night. That's 7300 exposures per year or 49000 exposures overall. That's a 1216% increase over a "promiscuous person" (300 partners/yr) and a 14600% increase over an average person.

So unless you are busier than a free Taxi in London..... giving rides to anyone who wants them. I think your risk level is lower.

My understanding is that the other superinfection cases are similar in profile to this sort of extreme risk behavior.

One last tidbit.... the reason you haven't seen much superinfection is that it's reasonably difficult to identify.... when was the last time your Doc did inventory on the variations of virus present? IBM did a study which I can't seem to locate right now, but they took blood samples and analyzed them for HIV variations. They found that the average individual had many mutations in their blood... .this synchs up with HIV's known history of mutating rapidly and constantly.

Anyhow, I'm not encouraging you to toss your condoms and become a slut. I am encouraging you to do your research, form an opinion, and choose a course of action that is rational and balances your need for personal safety with your need for intimacy.

As for other bugs.. yea HIV aint the only bug on the farm. And most of the others are easier to catch... so you should ensure that your bloodwork includes regularly screening for syphillis.

As for elevated liver numbers.... have you gained weight? My personal demon has been Fatty Liver Disease .... apparently quite common and free when you are infected with HIV! Wow..... anyhow the solution is to lose weight gradually and watch my diet like a hawk. Speaking of which, it's time for an ice cream cone.... just cuz I watch what I eat doesn't mean I have to eat like crap. And just because I'm poz doesn't mean I can't have good sex that meets my needs.

Logged

Don't obsess over the wrong things. Life isn't about your numbers, it isn't about this forum, it isn't about someone's opinion. It's about getting out there and enjoying it. I am a person with HIV - not the other way around.